Global Insurance Network, Inc.

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Bond Type:

Effective Date Needed:		Bond Amount: $
Principle Name: Full legal name as it must appear on the bond.		Tax ID # or SS#:

Business Address:
Business City:
Business State:
Business Zip:

Phone:		Fax:
Email:

Entity:

Corporation

Partnership

Individual/Sole Proprietorship

State of Inc.
Name
List All Partners

Additional Offices
If Yes, where?

Current Bond Agent:		Current Surety:
Reason For Switching:
Years in Business:	if less than 2 years, provide principal's experience
List all Names, if any, that you, your partners or your spouse previously worked under:

Has any Bond Principal
	Filed Bankruptcy?
	Failed in any Business Venture?
	Been the Subject of a Federal tax lein?
	Indemnified Others?

Principal Owners Name: If a partnership, please list all owners
Owner's S.S. No:
Spouse's Name:
Spouse's S.S. No:
Principal Owners Address:
Principal Owners City:
Principal Owners State:
Principal Owners Zip:

INDEMNITY: The undersigned represents that the foregoing statement is true and in consideration of the execution of this bond and as an inducement to such execution by surety, the undersigned agrees to:
1) Indemnify the surety and hold harmless from all loss, contingent loss, liability and/or contingent liability claim, including attorney fees, for which surety or agent shall become liable for shall become continently liable, by reason of having executed this bond and;
2) Pay any premium due for any bond computed according to the rates currently in effect with surety or agent, including renewal premiums, until proof satisfactory to surety is furnished of its discharge from any liability under this bond.

Name of Principal

Date

PLEASE PROVIDE A CURRENT, YEAR-END FINANCIAL STATEMENT, PREFERABLE AUDITED. PLEASE NOTE THAT A PERSONAL AND CORPORATE INDEMNITY AGREEMENT WILL BE REQUIRED, IF APPLICATION IS APPROVED

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